CATEGORY: ORGANS & TISSUES STEM CELL TRANSPLNTATION

Stem Cell Transplantation

Andy McLarnon, Birmingham, UK

Stem cell transplantation (SCT) is widely used to treat haematological malignancies such as
lymphomas, multiple myeloma and myeloid/lymphoblastoid leukaemias. It is potentially
applicable as a treatment for some solid organ tumours such as breast cancer and renal cell
carcinoma, and is increasingly used to treat non-malignant conditions. The principle is to ablate the

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immune system and replace it with haematopoietic stem cells from either the patient
(autologous-SCT), or from a HLA-matched donor (allogeneic-SCT).
There are different methods for harvesting stem cells. Either cells can be removed directly from the
donor’s bone marrow cavity, or the donor can be given granulocyte colony stimulating factor (G-
CSF) to mobilise their stem cells to the peripheral blood where they can be harvested. Cord blood
can also be used as a source of stem cells. Following the patient’s conditioning, the donor stem
cells are infused and migrate to the bone cavities to repopulate the immune system through
homeostatic mechanisms. The time of full reconstitution varies between patients and is often
dependent on the conditioning regimen.
Myeloablative conditioning ablates the patient immune system using a combination of high-dose
radiotherapy and immunosuppressive drugs such as cyclophosphomide or busulphan. This is a
highly toxic treatment so the number of patients that could be treated by SCT is limited to those who
are fitter and often younger in order to survive the conditioning. Other less intensive conditioning
(non-myeloablative or reduced intensity conditioning [RIC]) regimens have been developed
more recently, using different chemotherapeutic agents and/or lower doses of radiation which has
increased the number of patients for whom SCT is a treatment option.
Figure 1. Types of transplant
Immune-reconstitution post-
myeloablative and reduced
A Total Body Irradiation (TBI) Myeloablative intensity conditioning
transplantation.
Chemotherapy
During myeloablative
transplantation (A) the
Patient immune system is ‘donor’
Immune following infusion, whereas
System
following reduced intensity
conditioning (B) there is a
Donor period of mixed chimerism
Immune (‘patient’ and ‘donor’ mixture).
System Reduced Intensity Conditioning (RIC)
Chemotherapy

B Stem Cell Infusion

Due to the non-myeloablative nature of the reduced intensity conditioning, following infusion there is
a period of mixed-chimerism with both patient and donor cells present. The donor cells should
eventually out-compete, leading to the immune system becoming fully donor (Figure 1).
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 CATEGORY: ORGANS & TISSUES STEM CELL TRANSPLANTATION

Stem Cell
Transplantation
cont.
Donors are selected on the basis of HLA-compatibility. The more closely matched the donor and
recipient are, the less risk of potentially life-threatening graft-versus-host disease (GvHD) where
the new donor immune cells attack recipient tissues, often skin, gut and liver (Figure 2). This can
be very debilitating or even fatal.
An important effect following SCT is graft-versus-leukaemia (GvL), which is essential to prevent
relapse when treating malignant disease. Both of these effects are thought to be mainly T-cell
mediated and GvHD incidence is associated with decreased risk of relapse. Studies have shown
that one group of important GvL targets are haematopoietically expressed minor
histocompatibility antigens (mHAgs), such as HA-1. However it has also been observed that
there are GvL reactions following syngeneic transplantation which are unlikely to be caused by
mHAg mis-matches, suggesting that GvL could also have a tumour-specific component. This could
potentially be directed against tumour-specific antigens such as the cancer-testis antigen (CTAg)
family of tumour proteins, or antigens such as PRAME which can be overexpressed by tumours.
Although cancer patients may develop tolerance to tumour-associated antigens, SCT can facilitate
development of effective immune responses as the donor system is unlikely to have become
tolerised to these cancer proteins.
Occurrence of GvHD presents problems, but has been linked to a decrease in relapse risk,
probably due to GvL. Consequently, there is much research interest in trying to enhance the GvL
effect whilst simultaneously reducing GvHD.

Figure 2. Example of severe

graft-versus-host disease
manifested in the skin of an
allograft patient

http://www.cmaj.ca/cgi/content-nw/full/170/10/1569/F432